Postgrad Med J 1997; 73: 17-22 © The Fellowship of Postgraduate Medicine, 1997

Developing the role of the nurse specialist

Expanding the role of the nurse in theAccident and Emergency departmentBarbara L Neades

SummaryIn response to the increasing de-mands upon the Accident andEmergency department and sup-ported by changes within thescope of professional practice ofthe qualified nurse, Accident andEmergency nurses have expandedtheir role within the multidisci-plinary team. The article reviewsthe development of this expandedrole for the nurse within theAccident and Emergency teamand discusses its implications.

Keywords: nurse, Accident and Emer-gency medicine

Six principles of professionalpractice9* recognition that nursing practice is

undertaken to meet the needs ofpatients

* continual striving for knowledge andskills that provide safe andcompetent care delivery

* recognition of personal limitations ofskill and knowledge and endeavourto reduce these to ensure theappropriate meeting of patient needs

* recognition that expansion of rolemust maintain continuity and safetyof patient care

* recognition of the accountability ofother healthcare workers involved inthe care and treatment of patients

* ability to delegate appropriately

Box 1

South East Wales Institute of Nursingand Midwifery Education, CaerleonEducation Centre, St Cadocs'sHospital, Caerleon, Gwent NP6 1XR,UKBL Neades

Accepted 7 February 1996

Despite government initiatives to improve the primary care system within theUK,' Accident and Emergency (A&E) department attendances continue to rise.The National Audit Office indicated that in 1990/91 11.2 million new attenderswere seen in England and 1.2 million in Scotland.2'3

Jones4'5 highlights how seven out of nine national Patients' Charterstandards6 have been written specifically for A&E departments, suggestingthe need for the development of new strategies of care for the patient withinA&E. In addition, the Calman report,7 government strategies to reduce juniordoctors' hours8 and the publication of the Scope of professional practice fornursing, midwifery and health visiting,9 have arguably changed the face ofA&E services within the UK.The most controversial of these changes has been the expansion of the role of

the nurse within the A&E department.10 A debate has ensued as to theappropriateness of the changes in medical and nursing roles in an effort toimprove care in A&E. Some professionals welcome the changes which havetaken place within nurse education and practice, which allow the developmentof the nurse's knowledge and skills.11"'2 Others, however, lament the changesoccurring within nursing, suggesting that there has been an erosion oftraditional nursing values such as care, compassion and loyalty.13-'5 This paperreviews the development of the role of the nurse specialist within the A&Emultidisciplinary team, examining some of the issues raised by thesedevelopments.

The nurse specialist in A&E

In the light of government guidelines on extended roles,'6 A&E nurses haveadapted their role to include tasks previously undertaken by medical staff,including suturing wounds, plastering fractures, and recording of electro-cardiograms. Jones'7 found that normal practice for nurses in these departmentswas impossible to establish, such was the variety of skills being undertaken. Thetraining and legal cover provided by health authorities across the country wassimilarly varied. Other authors report the routine involvement of experiencedA&E nurses in the triage ofA&E patients,'8 X-raying of patients with potentialfractures,'9'20 and cannulation of patients.2'The practice of these 'extended roles', however, is controlled by protocols

established by individual health authorities. Nurses have reportedly felt theirpractice was curtailed by the need to achieve certificates of competence for eachindividual extended role.22 The introduction of the Scope ofprofessional practice,9however, has recognised the need for nurses to have a broad area of knowledgeand skills to meet the demands of society. In this document, nurses areinstructed that their practice must be 'sensitive, relevant and responsive to theneeds of individual patients'. Utilising the six principles of practice laid downwithin this document (box 1), together with the Code of ProfessionalConduct,23 A&E nurses are now free to identify potential areas of expansionto their practice which they consider to be beneficial to patient care. The UKCentral Council (UKCC),9 however, highlights the requirement for nurses toadhere to a safe standard of care and competence, gaining suitable experienceand education prior to expansion of practice.The National Health Service (NHS) Management Executive24 recognised the

benefits of utilising the skills of nurses and health visitors to enhance the qualityof care. This review of the boundaries of practice was welcomed by A&E nurseswhose attempts to expand their role had often been frustrated by existinglegislation.6 The support and freedom contained within the Scope ofprofessionalpractice has allowed A&E nurses to make a greater contribution to themultidisciplinary team. However, there is still considerable debate about theappropriate role of the nurse in A&E.

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Triage priority systemPriority 1: patients who requireimmediate attentionla: standby, immediate medicalintervention on arrivallb: must be seen by medical staffwithin 15 minutes of arrival

Priority 2: must be seen by medical staffwithin one hour of arrival2a: need on medical grounds2b: need on social grounds

Priority 3: can safely wait up to threehours for medical attention

Priority 4: while these can waitindefinitely for treatment, a maximumof four hours has been established

Box 2

Triage in A&E

The advancement of nurse triage is one of the main objectives of the RoyalCollege ofNursing's A&E Nursing Association,25 and has been called one ofthemost important developments in A&E departments within the past decade.5Triage of A&E patients, ie, the assessment of patients on arrival to determinetheir priority of care, was adapted from military medical practice.26 This systemof prioritisation (box 2), permits life-saving measures,27 first-aid, and/or theinitiation of diagnostic measures28 to be made appropriately. In addition, it canreduce patient anxiety and frustration by providing prompt assessment andinformation to patients, relatives and friends.29'30 It has also been suggested thatthe procedure makes the best use of A&E department resources, by directingthe patient to the most appropriate care area.30

Immediate assessment on arrival in A&E now forms the basis of one of thequality standards within the Patients' Charter. The term 'immediate' has beencriticised as being impractical and, although clarified as meaning within fiveminutes of arrival, it remains controversial.A debate also exists as to how, when, and where triage occurs. Crouch31

identifies three methods of triage:* before registration of the patient* with registration of the patient* after registration of the patient.Blythin27 advocates the application of the first method of triage, which requiresthe triage nurse to be situated in or near the waiting area and undertake apreliminary assessment of the patient. This method is favoured by manypractitioners in an attempt to achieve Charter standards. Other practitionershave adopted a combined triage and registration occurring within the waitingarea.The triage nurse has a responsibility to record any assessments made of the

patient's needs.23 Some authors have estimated that it can take up to 10 minutesto complete a full triage history.32 This delay may result in failure to achieve thePatients' Charter standard.To address this requirement some departments have developed a two-stage

system of triage. The first stage entails a brief history taking and superficialassessment of the patient by an experienced nurse to identify any immediaterequirement for care. Brief documentation occurs here. Following registration,the patient undergoes an in-depth assessment by another nurse, with moreextensive documentation taking place. Two immediate problems can beidentified with this triage system. If the first triage nurse meets the Patients'Charter standards but breaches the Code of Conduct by not adequatelydocumenting the patient's problems, the nurse's accountability for practice issurely questionable.Another problem surrounding the triage of patients within the waiting area

relates to the confidentiality of patient information. Even the briefest ofassessments entails the triage nurse requesting personal information from thepatient. Unless there is a specially allocated area within the waiting area, thisconfidential information may be overheard by other patients or relatives. Thismay constitute a breach of confidentiality.To alleviate these difficulties, other practitioners have adopted a system

where the patient is registered first and then proceeds to a specially designedarea where a full triage assessment is undertaken and documented. This mayresult in the department falling short of the Charter standard. Supporters of thismethod of triage acknowledge this difficulty, but suggest that the benefits interms of quality outweigh the problems of patients not being assessed'immediately'.The benefits of triage in relation to the reduction of patient waiting times in

A&E has also been the subject of considerable debate. Some observers33 suggestthat triage can reduce overall waiting times forA&E patients. It is also suggestedthat triage reduces anxiety and dissatisfaction of patients and relatives withlower priorities of care, by allowing them early access to a qualified nurse forassessment.29 Other studies,34'35 however, challenge the role of triage inreducing waiting times to treatment, suggesting that it may actually increasewaiting times. Some also suggest that there is no discernible difference inpatient satisfaction between groups of patients who are triaged and those whoare not. It is acknowledged, however, that these findings may only reflect localpractices.

Geraci and Geraci,36 in investigating factors which contributed to delayedtriage of patients, supported the theory that inadequate staff resulted inextended triage times. The triage nurse becoming involved in what theydescribed as non-primary triage functions during triage (eg, answering

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The role of the nurse in A&E 19

Potential benefits of nursetriage* assessment of patient's priority of

care on arrival* provision of first aid/life-saving

interventions* reduction in anxiety and frustrationby prompt assessment

* provision of information to patientsand relatives

* more efficient use of resources byearly and appropriate directing ofpatients

* achievement of Patients' Charterstandard

Box 3

Potential benefits ofEmergency NursePractitioner systems* earlier assessment and treatment,and discharge of some patientswithout referral to a medicalpractitioner

* improved utilisation of seniornursing personnel

* reduction in waiting time totreatment for patients in certaincategories

* earlier initiation of diagnosticmeasures

* improved provision for counsellingservices/health promotionopportunities

* redistribution ofA&E workloadbetween senior nurses and medicalstaff

* earlier referral of patients to otherhealth professionals, if appropriate

* allow senior nurses to developadvanced skills which are available tothe public

* provide a walk-in service for patientswhere medical practitioners notrequired, eg, nurse-run minorinjuries units

Box 4

telephone requests for advice, interruptions from other healthcare professionalsand giving directions and retrieving records for medical and other staff), had amajor influence on poor triage time outcomes.At the heart of this debate lie the fundamental goals and potential benefits of

triage (box 3). Triage can also be viewed as an opportunity for the nurse tocommunicate with the patient and family, providing information as well ashealth promotion and accident prevention advice, with emphasis on the qualityof contact with the patient. Others view triage as a function of the A&Edepartment's attempts to achieve the Charter standard of assessment of allpatients within five minutes of arrival.The A&E specialist must therefore consider whether their application of

triage is providing the envisaged improvements in the quality of patient care ormerely addressing the Charter requirements in terms of time.

Telephone triage

A further development in A&E nursing has been the establishment of anextended triage system utilising the telephone.37 Evans et al,38 note how thepublic often telephone the A&E department for advice. Telephone triageinvolves the nurse providing advice to the public on health-related matters. Inaddition, decisions regarding appropriate first aid, the need for the patient toseek professional healthcare or ability to self-care, may also be made by thenurse.39 Wilkins (unpublished) has highlighted the financial savings to thehealthcare system that can be obtained by instigating such a service.Some practitioners, however, question the accountability related to this

practice within A&E nursing.38'40'41 They highlight how some telephone triagesystems appeared to operate on a very ad hoc basis, with little reference tostructured protocols or documentation. Edwards41 explored the diagnosticreasoning utilised by nurses during telephone triage. He found that nursesutilised a systematic approach to making decisions on appropriate patientadvice, and rejected the requirement for formal telephone triage protocols.Other authors dispute this, however, suggesting that, when protocols of practiceare not utilised, some of the information provided could be inappropriate andeven harmful to the patient.38'40'42 Given the variety of requests for advicereceived in the A&E department, they question the triage nurse's ability tocomment adequately and safely on every care aspect without the aid of someform of acceptable protocol.

Dale et al°4 also support the need for protocols and additional education forthe nurse, highlighting the stress associated with being inadequately prepared.Education is crucial in dealing with situations requiring crisis interventionskills, for example, in dealing with an attempted suicide. These authorsadvocated the use of well-developed protocols of practice and have devised acomputer data base of information which could be used as part of a telephonetriage system.

Telephone triage has the potential to enhance greatly the quality of careprovided by the A&E department. However, it is not the panacea for all ills. Itsdevelopment can only be achieved by multidisciplinary planning, appropriateresources and provision of adequate numbers of suitably prepared staff.

The Emergency Nurse Practitioner

Another initiative within A&E nursing has been the development of EmergencyNurse Practitioner systems throughout the UK. These have been welcomed bythe medical profession,43'44 the government45 and the National Audit Office,20seeing their potential to cut waiting times, improve care and reduce pressure onjunior doctors in A&E (box 4). Kohn46 documented the establishment of thefirst Emergency Nurse Practitioner service in this country and a number of suchschemes have now been established.47'48Each A&E scheme includes a variety of roles, for example, diagnosis and

treatment of minor injuries, referral to other health professionals, and healthpromotion activities. The Royal College of Nursing49 has attempted to definethis role (box 5). In some practices, for example, some diagnostic tests (eg, X-rays) may be requested by the Emergency Nurse Practitioner prior to thepatient being seen by the doctor.50 The health promotion aspects of the roleare also highlighted, demonstrating how the Emergency Nurse Practitioner'sknowledge and skills can be further utilised to care for vulnerable groupswithin inner city areas (Crouch, personal communication). The scope ofpractice of this role, however, varies according to local requirements. In someareas the Emergency Nurse Practitioner is employed solely in this role,allowing development of specialist practice areas. The Emergency Nurse

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The Emergency NursePractitioner: definition49

An Emergency Nurse Practitioner inA&E is a nurse who has a soundnursing practice based on all aspects ofA&E nursing, with formal post-basiceducation in holistic assessment,physical diagnosis, prescription oftreatment and promotion of health.The Emergency Nurse Practitioner is akey member of the healthcare teamdirectly available to members of thepublic. He/she must be an autonomouspractitioner, able to assess, diagnose,treat and discharge patients withoutreference to a doctor, but within pre-arranged guidelines. He/she must beable to make independent referrals toother healthcare professionals

Box 5

Education available forEmergency NursePractitioners

* a generic education programme,leading to a Health NursePractitioner award

* separate module as part of a Mastersdegree

* short programmes developed andprovided by individual healthauthorities/A&E departments

Box 6

Implications of EmergencyNurse Practitioner systems* development of detailed protocols of

practice for the emergency nursepractitioner in each trust on amultidisciplinary basis

* provision of vicarious liability by theemploying authority for eachemergency nurse practitioner

* provision of appropriate educationprogrammes

* possible de-skilling of the emergencynurse practitioner in other aspects ofA&E nursing

* inappropriate utilisation of theemergency nurse practitioner as asubstitute for junior medicalpersonnel

Box 7

Practitioner may undertake such advanced roles as the assessment andtreatment of hand injuries, as well as developing a health promotion/accidentprevention role within the community (Keltie, personal communication). Thismay further reduce attendances and waiting times within major A&Edepartments.

Critics of this approach suggest that this may mean deskilling of theEmergency Nurse Practitioner in other aspects of A&E nursing, eg, resuscita-tion, teaching, and management of the A&E department.48 They favourcombining the role with that of the department Sister.

Supported by guidance from the Royal College of Nursing,49 someEmergency Nurse Practitioner schemes have now been developed as nurse-led minor injuries units.51 These units often provide minor injury care followingthe closure of the major A&E department. They may also refer patients to on-site physicians, psychiatrists and physiotherapy services, or to the major A&Edepartment, and may administer medication to the patient according to agreedprotocols. There have been problems, however, with the development of thisrole. Howie52 highlights the inter-professional difficulties experienced with theEmergency Nurse Practitioner requesting X-rays. Davies'l recognised theconsiderable pressures on the Emergency Nurse Practitioner. She suggests thatthe role of the Emergency Nurse Practitioner is often seen only in terms ofwhatthe nurse can do from a task-orientated perspective and as a doctor substitute toreduce junior doctors' hours.Some authors have vigorously disputed the suggestion that nurse practi-

tioners should be utilised as junior doctor substitutes."153 They list directimprovements in the quality of patient care gained from this role, includinglistening/counselling services, support, and monitoring the health of patients, inaddition to the care of their minor injuries.

Castledine54 advises that any nurse practitioner carrying out medicallyorientated procedures should ensure that they adopt an approach 'incorporatinga nursing focus of caring, comforting and counselling', lest they become nomore than technicians undertaking tasks on behalf of the medical practitioner.Dowling et al,55 also question whether, as a result of the nurse taking on moretechnical roles, the highly valued nursing characteristics of caring andcommunication might suffer.Touche Ross56 evaluated the work ofnurse practitioners at 20 sites, including

A&E. They reported the improvements in care made by the nurse practitioner,highlighting the provision of safe and effective care. They did suggest, however,that this did not necessarily result in cost reductions.Dowling et al,55 and Wilson57 have also raised doubts about the proposed cost

savings in expanding the nurse's role to reduce the workload of the juniordoctor. They indicated that the limited role developed for some nursepractitioners did not make them cost effective.To some, the Emergency Nurse Practitioner is the answer to all the

problems of the A&E department. The Emergency Nurse Practitioner cannotonly care for the minor injury patient but, in addition, may redirect patientswho do not require treatment in the A&E department. The resolution of the'inappropriate attender' dilemma is nigh! Cable (unpublished) suggests,however, that these patients' non-requirement for medical care, does notnegate the benefits they could accrue from the listening, supportive, andhealth-promotion skills of the Emergency Nurse Practitioner. He questionsthe practice of redirecting these patients away from A&E because they do notrequire medical intervention.

In response to financial pressures some A&E managers are now consideringsubstituting the Emergency Nurse Practitioner for the junior doctor in A&E,with considerable implications for both professions.

In addition to the professional implications of the establishment of anEmergency Nurse Practitioner system, the legal and accountability aspects ofthe role also require consideration. The need for vicarious liability from theemployer necessitates the establishment of detailed protocols of practice for theEmergency Nurse Practitioner whilst in the employ of that particular healthauthority/trust and is not transferable.The educational implications of providing this service are also considerable.

The Royal College of Nursing49 defines the Emergency Nurse Practitioner as anurse with a sound base in A&E and appropriate formal post-basic education.The education available for this role varies considerably (box 6). Walsh58suggests the need for a nationally recognised education programme to developand maintain standards of practice. Developing these courses requiresconsiderable time, finance, and multidisciplinary support.

If the full potential for this role in patient care is to be realised, theEmergency Nurse Practitioner should not be viewed as a replacement for the

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The role of the nurse in A&E

junior doctor, but as a professional with qualities and skills which complementthose of the medical staff in A&E. This is not a quick or cheap solution to theproblem of irTcreasing A&E attendances.5 There must be inter-professionaldiscussions to clarify the manpower, educational and professional/politicalimplications of the Emergency Nurse Practioner's role (box 7). In addition,further research to determine the appropriate scope of practice of theEmergency Nurse Practitioner and to establish the position of the EmergencyNurse Practitioner within the multidisciplinary A&E team must be undertakenif this unique opportunity to enhance A&E care is not to be missed.

Resuscitation of acutely ill patients

A&E nurses now undertake a much more active role within Advanced LifeSupport and Advanced Trauma Support Resuscitation teams.5960 Lomas andGoodall6l suggest that a structured and organised team with predeterminedroles and responsibilities for both nursing and medical staff, can have a directbearing on patient outcomes in resuscitation. Utilising the specialist knowledgeand skills gained during the Advanced Life Support Course,62 AdvancedTrauma Nursing Course,6' or the Trauma Nursing Core Course,64 experiencedA&E nurses are now making a greater contribution to the care of patients withlife-threatening conditions. With these courses, recognised by the Royal Collegeof Surgeons and the Royal College of Nursing, the nurse not only gainstheoretical knowledge of the assessment and management of the patient with acardiac arrest or multiple trauma, but also develops the practical skills neededin resuscitation of these patients.

It is acknowledged that, in the UK, nurses are not often required toundertake advanced resuscitation procedures alone, such as the insertion ofchest drains or peritoneal lavage. However, nurses have been required tointubate and cannulate patients in an emergency situation.6" The experiencedA&E nurse is also often required to advise, support and sometimes direct juniormedical colleagues in an emergency situation, until more senior medical staffcan attend. The experienced A&E nurse must therefore have the appropriateknowledge and skills to support the junior doctor in the application of theAdvanced Life Support or Trauma protocols.

Together, these courses provide the nurse with a sound education so thatthey may undertake a full role within the cardiac or trauma resuscitation team.Indeed, a number of senior nurses are now certified instructors in AdvancedLife and Trauma Support. Utilising the knowledge and skills of the experiencednurse in this manner could be viewed as an effective use of departmentresources, allowing considerable improvements in the care of the critically illcardiac or trauma patient to be achieved.59 65 Gautam and Heyworth,66 however,claim that these courses are often inaccessible to nursing staff due to theirlimited availability and the lack of funding. Hadfield-Law65 suggests that, unlikethe medical staff who attend these courses, many nurses have difficulties inobtaining funding and study leave. Conaghan67 suggests that these courses areonly the first step to improving care, and highlights how quickly skillsdeteriorate after acquisition. She suggests that, without follow-up, practiceand support, these courses are a waste of money. Practice may be gained viaaccess to mannequins or, alternatively, by the utilisation of these skills on aregular basis, within a cardiac arrest or specialist trauma team.

Despite the availability of these educational courses and the publication ofthe Scope of professional practice, few senior A&E nurses who hold theappropriate qualification are utilised fully as part of such teams. Hospitalprotocols still often insist that medically qualified personnel should co-ordinateresuscitation attempts, even if the medically qualified person is a junior doctorwith limited experience in the field.

There is, of course, a legal requirement for a doctor to take responsibility forcertain procedures, such as the prescription of drugs. If, however, the nurse isrequired to administer a drug within an agreed protocol, the employingauthority can draw up an agreement with the nurse where vicarious liability willbe extended. This practice is limited, however. This situation raises somequestions as to the perception of the experienced nurse by the other members ofthe multidisciplinary team and the appropriate utilisation of this highlyeducated and expensive A&E resource.

If improvements in the resuscitation of critically ill patients are to continue,the development of multidisciplinary teams possessing advanced skills isessential. The experienced, trained, A&E nurse is an integral part of that team.Perhaps as a result of previous legislation and education we are not making thebest use of this resource. Clearly, this area merits attention, including areconsideration of professional and personal perceptions.

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